Clavicular Fractures & AC Joint Injuries

Above the rotator cuff is a bony mass that sits on the shoulder blade, or scapula, called the acromion. This constitutes the top of the shoulder. The acromion is the headquarters for the deltoid muscle and connects to the collarbone, or clavicle, to form the AC joint, or acromioclavicular joint. Problems often occur to this joint as a result of a fall or impact to the outside part of the shoulder. Often called an AC separation, these injuries are seen most often in contact sports and in biking and skiing falls.

When an AC separation occurs, patients will complain of pain and the presence of a bump on the top of the shoulder. The bump really is not new, but rather the end of the collarbone, which used to be connected to the acromion. Gravity causes the acromion and the rest of the arm to sag, which causes the end of the collarbone to appear larger.

Most of these problems can be treated without surgery. Dr. Sanders utilizes a Cryo/Cuff® to keep the area cold and compressed. This relieves pain and swelling. Advil or Tylenol is also effective for pain relief. After a very short period of rest, the same range of motion exercises used for Rotator Cuff injuries are employed to complete the rehabilitation and patients are back at their sport in two weeks.

In the rare case of a marked displacement and severe weakness of the deltoid muscle, an outpatient surgical repair is performed to restore the ligaments maintaining the acromioclavicular region. Following surgery, a Cryo/Cuff® is placed around the area, and immediate range of motion exercises begun. Most patients will be back in competition before two months time.

In many cases, arthritic degeneration of the acromioclavicular joint can occur even without history of a serious injury. This is often seen in weightlifters. Treatment is basically the same as for AC injury, with non-surgical methods preferred. Arthroscopic Shoulder surgery may be necessary in recalcitrant cases.

Not infrequently AC arthritis is coexistent with disorders of the rotator cuff. When this happens, treatments are directed to the rotator cuff problem. However, in those rotator cuff cases requiring surgery, surgical attention is also directed to the removal of the spurs - which exist on the terminal five millimeters of the clavicle and the most medial aspects of the acromion.

Clavicular Fractures

Fractures of the clavicle or collarbone are common injuries in sports, and among the most common injuries in cycling and off road motorcycling. Most off road motorcyclists will break either one or both during their career. This injury is no longer considered a minor one and displaced fractures that heal crooked will, in many cases, cause permanent problems such as pain, weakness, and deformity.

For fractures in the growing athlete, and nondisplaced fractures in the adult, the first five to seven days should be spent in a simple sling. Dr. Sanders does not advocate a Figure of Eight bandage for a fractured clavicle, as it does little to improve the position of the fractured bones. Nor does it relieve pain.

After a week to ten days, athletes may begin moving their shoulder - working on trying to lift it over their head and improve range of motion. Follow up X-rays must be taken in adults to assure that the minimally displaced fracture fragments do not migrate. Because of the young bone’s remarkable ability to remodel, a child’s clavicle will tolerate considerably more displacement than that of an adult. After six weeks, or when the clicking or popping sounds subside, patients may begin lifting lightweight objects - such as an unopened soda can - to build strength. Heavier weight can be added as comfort allows. Younger patients are back at their sport by eight weeks, while older patients require more time - usually three months.

When there is severe displacement, overriding of the fragments, fracture fragments threatening to pierce the skin, multiple fractures in the extremity, associated nerve injury, multiple rib fractures, or fractures close to the shoulder end of the clavicle - surgical treatment is necessary. While these high-energy fractures are not common in most sports, a great number of fractures incurred by motocross riders are of this type. In these more severe cases, surgical treatment is performed with a pre-contoured and locked plate and screws placed on the top of the bone. Commonly, bone graft is added to maximize the chances of early healing and speedy return to sports. Since the newer plates are titanium and the screws lock into the plate rather than compressing the plate to the bone, stress shielding of the bone is less likely and hardware removal is generally not necessary.

This procedure may be performed on an outpatient basis and will allow for early motion of the shoulder and upper extremity. It typically will result in bony healing before two months and a timely return to sports, particularly off road motorcycling.